1. Sagittal balance in thoracolumbar or lumbar congenital kyphoscoliosis and kyphosis at a minimum of 10 years after surgery : A case series Sagittal balance in thoracolumbar or lumbar congenital kyphoscoliosis and kyphosis at a minimum of 10 years after surgery : A case series Miyazaki S, Suzuki T, Inui Y, Kawakita K Dogaki Y, Kurakawa T, Uno K 9th ICEOS Annual Meeting, Boston, November 19-20 in 2015 Department of Orthpaedic Surgery National Hospital Organization Kobe Medical Center

2. DisclosureDisclosure Author Author Relationships Disclosed Miyazaki S Suzuki T Inui Y Kawakita K Dogaki Y Kurakawa T Uno K Uno K Miyazaki S Suzuki T Inui Y Kawakita K Dogaki Y Kurakawa T Uno K Uno K No Relationship

3. Postoperative sagittal balance in congenital kyphoscoliosis and kyphosis remain unclear. The restoration of proper sagittal alignment is crucial for obtaining satisfactory clinical outcome in adult spinal deformity. The restoration of proper sagittal alignment is crucial for obtaining satisfactory clinical outcome in adult spinal deformity. BackgroundBackground Glassman SD, et al. SPINE 2005

4. ObjectiveObjective To elucidate sagittal balance in thoracolumbar or lumbar congenital kyphoscoliosis and kyphosis at a minimum of 10 years follow-up after surgery To elucidate sagittal balance in thoracolumbar or lumbar congenital kyphoscoliosis and kyphosis at a minimum of 10 years follow-up after surgery

5. MaterialsMaterials 16 cases A retrospective analysis of the patients with congenital kyphoscoliosis and kyphosis Age (y.o.) : Age (y.o.) : Gender (boy ： girl) : Gender (boy ： girl) : 6 ： 10 6 ： 10 10.1 ± 3.6 10.1 ± 3.6 Vertebral anomalies At initial surgery Duration of follow-up (years) : 16.3 ± 4.0 Solitary simple Multiple simple ComplexComplex 6 cases 6 cases 7 cases 3 cases Kawakami N, et al. SPINE 2009

6. Posterior only 13 cases Anterior + Posterior 3 cases Surgical proceduresSurgical procedures 16 cases Additional Surgery 8 cases ✓ Pseudoarthrosis ✓ Adjacent segmental disease ✓ Coronal decompensation ✓ Sagittal decompensation 1 case 1 case ✓ Implant failure 2 cases 2 cases 3 cases 3 cases Number of fused segment: 1.3 above and 1.3 below Extension of fused segment

7. Radiological evaluations C7 Plumb line CSVL Coronal plane Sagittal plane ✓ Cobb angle of main curve ✓ Coronal balance ✓ Segmental angle of kyphosis ✓ Lumbar lordosis (LL) the angle between the lower endplate of LIV and the upper endplate of S1 the angle between the lower endplate of LIV and the upper endplate of S1 ✓ Sagittal vertical axis (SVA) ✓ Pelvic incidence (PI) ✓ Pelvic tilt (PT) ✓ Sacral slope (SS)

8. Results (Overall)Results (Overall) Pre OP Post OP Latest Main curve55.1 ±16.7 32.8 ±17.1 34.8 ±13.4 Coronal balance-9.8 ±17.1 3.3 ±18.6 4.2 ±8.8 Kyphosis33.9 ±20.1 15.7 ±18.3 16.4 ±21.8 LL44.5 ±28.0 37.1 ±22.4 34.7 ±19.1 SVA13.1 ±33.8 18.4 ±22.2 33.8 ±57.1 PT17.3 ±14.0 18.5 ±10.1 22.9 ±13.9 SS28.5 ±9.2 28.1 ±7.3 23.7 ±11.7

9. ✓ Proximal junctional kyphosis (PJK) ✓ Progression of the kyphosis Cases of sagittal imbalanceCases of sagittal imbalance showed more than 40 mm of SVA at latest follow-up and more than 30 mm positive shift of SVA during follow-up period. Pre OP Post OP Latest Kyphosis50.8 ±15.5 30.4 ±14.1 25.6 ±19.7 LL41.8 ±45.3 32.4 ±39.5 17.0 ±17.6 PT25.2 ±8.6 25.8 ±5.4 37.4 ±7.4 p<0.05 ＊ ＊ ＊ 1 case 1 case 2 cases 2 cases 5 cases

10. Post 2 nd OP 15 years Post 2 nd OP 7 years Post 2 nd OP 34°34° C7 Plumb line +38 mm +27 16°16° +105 21°21° 17°17° +30 28°28° 17°17° 78°78° 65°65° Th12 L1 Illustrative case reportIllustrative case report Pre OP (4 years old) 28°28°45°45°35°35°24°24° Kyphosis LL PT SVA

11. DiscussionDiscussion PJKPJK LL LL PT PT Pre OP Post OP Mobile segment Mobile segment Compensation Compensation Decompensation Decompensation DegenerationDegeneration ✓ The development of secondary changes could be avoided only by early and complete correction of the local deformity. by early and complete correction of the local deformity. ✓ The development of secondary changes could be avoided only by early and complete correction of the local deformity. by early and complete correction of the local deformity. Ruf M, Harms J. SPINE 2009 Our study Our study Sagittal imbalance Considering re-operation with extension of fused segment Considering re-operation with extension of fused segment Residual kyphosis Residual kyphosis Kyphosis Kyphosis Rigid & structural Rigid & structural

12. ConclusionConclusion Postoperative sagittal balance in thoracolumbar or lumbar congenital kyphoscoliosis and kyphosis could deteriorate due to residual kyphosis and decompensation in the sagittal plane despite the early correction and short fusion. Postoperative sagittal balance in thoracolumbar or lumbar congenital kyphoscoliosis and kyphosis could deteriorate due to residual kyphosis and decompensation in the sagittal plane despite the early correction and short fusion.